Ho c6 c7 120912 90m breastfeeding behavior frequency wna

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Ho c6 c7 120912 90m breastfeeding behavior frequency wna

  1. 1. A NeurobehavioralApproach to BreastfeedingDr Nils Bergman”M.D., D.C.H., M.P.H., Ph.D.”Cape Town, South Africawww.kangaroomothercare.com
  2. 2. BIRTHS S CBreastfeeding behaviourBreastfeeding WIRINGBREASTFEEDINGSENSORY BRAINstimulation nutritionSTATE organizationFeeding frequencySLEEP cyclingON-GOINGS S CBRAINWIRING
  3. 3. THE “OLD” BRAIN HAS3 PROGRAMMESDEFENCE NUTRITION REPRODUCTION
  4. 4. DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLES
  5. 5. The neurobehaviouralprogrammes originate in theLIMBIC SYSTEMExpressed throughhypothalamus NEURO(autonomic nervous system)hypophysis ENDOCRINE(endocrine system, hormones)cerebellum etc BEHAVIOR(somatic system)
  6. 6. DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLESendocrine autonomic NS somaticHIGHLY CONSERVEDNEURO-ENDOCRINEBEHAVIOR
  7. 7. DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLESHIGHLY CONSERVEDNEURO-ENDOCRINEBEHAVIOR
  8. 8. REPRODUCTIONNUTRITIONDEFENCEHORMONES NERVES MUSCLESHIGHLY CONSERVEDNEURO-ENDOCRINEBEHAVIOR
  9. 9. DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLESHIGHLY CONSERVEDNEURO-ENDOCRINEBEHAVIOR
  10. 10. BEHAVIORWHOLE BODYHORMONES NERVES MUSCLESHIGHLY CONSERVEDNEURO-ENDOCRINE
  11. 11. Clinics in Perinatology,June 2004, Vol 31(2) page 210Stanley GravenEarly neurosensory visualdevelopment of fetus and newborn.“It is a serious mistake to assume that theprinciples derived from careful animal studiesdo not apply to human infants.The risk of suppression or disruption ofneeded neuralprocesses ...
  12. 12. All mammals have set sequenceof behaviours at birth ………….……. All with asingle purpose : toBREASTFEED
  13. 13. After birth, events aredetermined …… by the neonatestimulating the mother!(Rosenblatt 1994)
  14. 14. Breast-feeding is “establishedthrough a set of mutual,complex sensory stimulationsin mother and child.”(Kjellmer & Winberg 1994)
  15. 15. The “habitat - niche” conceptHABITATDETERMINESBEHAVIOUR
  16. 16. The “habitat - niche” conceptBEHAVIOURENSURESBIOLOGICALNEEDS
  17. 17. Warming, feeding andprotection behaviours areintricately, inseparablylinked to the right place.(Alberts 1994)= NUTRITION PROGRAMME
  18. 18. In all mammals …….….. the newborn isresponsible forinitiatingbreastfeeding,not the mother !!
  19. 19. In all mammals …….….. the newborn isresponsible forinitiatingbreastfeeding,not the mother !!EXCEPT IN HUMAN ???
  20. 20. Sequence human newborn breast-feedingPre-requisite = habitathand to mouthtongue movesmouth moveseye focuses nipplecrawls to nipplelatches to nipplesuckles(Widstrom et al 1994)
  21. 21. “The newborn may appearhelpless, but displays animpressive and purposefulmotor activity which, withoutmaternal assistance, brings thebaby to the nipple.(Michelson et al 1996)
  22. 22. “The newborn may appearhelpless, butraises its own temperature,has a higher blood glucose,metabolic adaptation faster.(Widstrom 1987)
  23. 23. METABOLIC ADAPTATIONSSC started in the first20 minutes after birthSSC CotBlood glucose (1 hr) 3.17 2.56Base excess drop 3.4 1.8(Christenson 1992)
  24. 24. Warming,feeding andprotectionbehaviours areintricately, inseparablylinked to the right place.(Alberts 1994)
  25. 25. Animal literature does not talkabout mammalian lactation,it talks about mammalian birth.Ruin the birth – andthere is no lactationWith a good birth,lactation followsDiane Weissinger
  26. 26. PSN envisions a community thatembraces its mothers and babies, andvalues the uniqueopportunity at birthto impact the physical and emotionalwell-being of the newborn.
  27. 27. Target #1 for 2005:Report that 65% of infants areplaced and remain indirect skin to skin contactwith their mothersfor at least one hourduring the first 3 hours after birth.
  28. 28. Skin-to-skinandbreastfeeding(4)01020304050607080901003Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07Breastfeedingintention Skin-to-skinonehour BreastfeedingatdischargeUsed with permission: Ruth Stanhiser, MDBabies breastfeedingMothers intendingto breastfeed
  29. 29. More skin-to-skin  more breastfeeding
  30. 30. DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLESendocrine autonomic NS somatic… highly conservedneuro-endocrine behaviors
  31. 31. BREASTFEEDINGIS A BEHAVIOUROF THE NEWBORNNot the mother !!
  32. 32. DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLESendocrine autonomic NS somatic… highly conservedneuro-endocrine behaviors
  33. 33. Animal literature does not talkabout mammalian lactation,it talks about mammalian birth.Ruin the birth – andthere is no lactationWith a good birth,lactation followsDiane Weissinger
  34. 34. BREASTFEEDING THE PREMATUREPremature babies will need help.BERLITH PERSSONhas provided that help …PERSSON’S WHEEL !
  35. 35. KERSTIN HEDBERG-NYQVIST:(Early Human Dev 55 (1999) 247 -264.)PIBBSPreterm Infant Breastfeeding Behaviour Scalerooting 0 - 2areolar grasp 0 - 3latch (and fixation) time 0 - 3sucking 0 - 4longest sucking burst 1 - 6swallowing 0 - 2
  36. 36. KERSTIN HEDBERG-NYQVIST:PIBBSPreterm Infant Breastfeeding Behaviour ScaleNutritive sucking = >5ml swallowedFull breastfeeding = exclusive Brf
  37. 37. KERSTIN HEDBERG-NYQVIST:(Early Human Dev 55 (1999) 247 -264.)PIBBSPreterm Infant Breastfeeding Behaviour ScaleEARLIEST OBSERVATION:(weeks PMA) 28 29 30 31 32 33 34 35 36rooting 90%grasp 50%latch 95%sucking 90% Nutritiveswallow Effectiveburst >30sucksFull breastfeeding 33w
  38. 38. Step 1 SKIN-TO-SKINContinuous skin contactThe newborn must be in the rightenvironment for the behaviours thatit is capable of to be expressed. Itrequires protection from stress andprovision of warmth.KMC provides the “maternal nest”1SSCIdeally this should be done on prematures AT BIRTH.However it can be done later, even with nasogastric tubeproviding expressed breast milk in the meantime
  39. 39. Step 2 and 3 OlfactoryThe first steps in sequencerequire smell of the nipplewhich may take longer inthe premature,and then the smelling of milk.Babies can identify smells andtastes from their time in theuterus in the mother’s milk!23Smell nippleSmell milk
  40. 40. 45Step 4 TasteThis is re-inforcing the smell.Fullterm seems to skip this!Step 5 RootingThese are mouth movementsthe normal sequencedescribed in the full-terms.Here the prematurerequires help, with positionand “sipping”= feeling milk in mouthTaste milkRootingSipping
  41. 41. 6Step 6 First suckling.Key step, builds on steps 1 to 5.Must be awake and alert.Alert period is maximal at birth,and lasts 45 - 90 minutes.If missed then, will require feeding,and several hours delay.AlertforSuckling
  42. 42. 6Step 6 First suckling.Note difference suckling vs sucking!“ … myographically distinct”For late premature lactation, allowsuckling to develop in successivealert periods, while feeding by tube.AlertforSuckling
  43. 43. From 16 or 20 weeks gestation,the fetus is swallowing.From 26 or 28 weeks gestationthe fetus can SUCKLEFrom 36 weeks gestation thefetus is able to SUCKSUCKING and SUCKLINGsound same, but VERY differentBreastfeeding & Suckling
  44. 44. 7Step 7 Latching & swallowingPremature is too physicallyweak to crawl to nipple,but if held to nipple will atthis stage latch on.Once latched, suckling follows.Suckling squirts acontrolled dose of milkto the back of throat, whichis safely swallowed without anyinterference of breathingThis is INNATE.LatchingSwallowing
  45. 45. 8Breast mealStep 8 First breast milk meal.Steps 1 to 7 and on take placerapidly in the fullterm.They can occur in the firstalert period after birth in apremature if allowed to,butmay require a longer periodof defined steps in successivealert periods. For late premlactation, step 8 is the firsttime milk is swallowedEnough to feed the baby.
  46. 46. 910Frequent feedingTogethercontinuouslyStep 9 Frequent feedingIn utero, baby is feedingContinuously.Demand feedingis NOT SUITABLE for prematures.Feeds should be atmost 2 hours apart.Step 10Together continuously
  47. 47. The wheelis notroundTurnsslow atfirstbutthenpicksup speed!
  48. 48. BREASTFEEDING APREMATURESTEP 1 SSCSTEP 2 ALLOW TIMESTEP 3 State organisation:alert awakeSTEP 4 SMELLSTEP 5 TASTESTEP 6 LATCHSTEP 7 SUCKLENUTRITION
  49. 49. © 2001 Nils Bergman© 2001 Nils BergmanBABY STOHM PREM BREASTFEED:SEE WEBSITEhttp://www.kangaroomothercare.com/stohm-breastfeeding.aspx
  50. 50. THE NEWBORNalso has a larynx that meets theuvula, designed to separate therespiratory tract from thegastrointestinal tract ,enabling the newborn to feedand breathe simultaneously.
  51. 51. BottleBreastBaselinepO2BaselinepO2Start feed Ends feed 10 min laterSuckingburstRestTakes longerSucklingcontinuousNon-nutritiveSuckingburstMeier 1988BOTTLE AND BREASTFEEDING IN PREMATUREPrematures babies weighing 1300g and 34/40 PCA,given alternating bottle and breastfeeds.
  52. 52. (Chen et al 2000)25 babies in 80 sessions, all <1800g“There were 2 episodes of apnea and 20episodes of oxygen desaturation during bottle-feeding and none during breastfeeding.We conclude that breastfeeding is a morephysiological feeding method for the preterminfant and bottle-feeding may be morestressful.”BOTTLEFEEDINGIS STRESSFULand DANGEROUS
  53. 53. SUCKLING uses the largest muscle inthe baby’s head, makingthe smallest movementSUCKING requires lots of tiny andweak muscles, makingmaximum effort,… also causes hypoxia,… and is STRESSFUL !
  54. 54. Bottle feeding requires SUCKING,which requires completely differentmuscles, and does NOT allow co-ordination between swallowing andbreathing. Bottle feeding causes STRESS inprematures, and relative post-prandial hypoxaemia.SUCKLING - in and of itself,apart from nutrition intake -has beneficial effectson both mother and baby.SENSORY STIMULATION ....
  55. 55. Sucklinginduces simultaneous endocrineeffects in the gutof both mother and childthere is a physiologicalsymbiosis between them.Breast feeding also has psychic effects;CCK is produced,which induces sedation and sleep.
  56. 56. STATE ORGANISATION.The ability to appropriatelycontrol the level ofsleep and arousal.
  57. 57. Simplified scale -HARD CRYINGCRYINGFUSSINGACTIVE AWAKEQUIET AWAKEALERT INACTIVEDROWSYACTIVE SLEEPIRREGULAR SLEEPQUIET SLEEPDEEP SLEEPL to R shunting, IVH riskStressful, wastes calories,… build up to stressThis is feeding zone!Time to connect - stimulation… transition zone… transition zone… activity consumes caloriesGood sleep - digestion zoneApnoea zone !!STATE ORGANISATION.
  58. 58. Simplified scale -HARD CRYINGCRYINGFUSSINGACTIVE AWAKEQUIET AWAKEALERT INACTIVEDROWSYACTIVE SLEEPIRREGULAR SLEEPQUIET SLEEPDEEP SLEEPIncubatorSSC
  59. 59. Simplified scale -HARD CRYINGCRYINGFUSSINGACTIVE AWAKEQUIET AWAKEALERT INACTIVEDROWSYACTIVE SLEEPIRREGULAR SLEEPQUIET SLEEPDEEP SLEEPriskstressfeedingstimulationdigestionapnoeaKMC babies oscillate slowly in safe zonesSeparated babies oscillateerratically to danger zones
  60. 60. rest-activity cycleis approx 60 minutes long(Ludington 2006)
  61. 61. Not so much duration,or density of any sleep stage,or number of sleep stage episodes, but,cycling between quiet sleepand active sleepis what is important
  62. 62. SLEEP CYCLING –Separation vs contactIn SSC:• Normal cycling• Non-chaotic pattern48 hour baseline chaotic pattern ofactivity and quiet HR & RRPre-KC SSC
  63. 63. “The newborn may appearhelpless, but displays animpressive and purposefulmotor activity which, withoutmaternal assistance, brings thebaby to the nipple.(Michelson et al 1996)
  64. 64. Gut hormones.(Uvnas-Moberg 1989)20 different hormoneswork in the gut –regulated by the vagal nerve.Each has a specific function.
  65. 65. Gut hormones."Bad guy" - SOMATOSTATIN:(produced by fetus, rise 10-fold under stress)inhibits gastrointestinal secretion,inhibits motility ,reduces blood flow to gutand absorption,causes gastric retention,vomiting, constipation.
  66. 66. SOMATOSTATIN:inhibits the good hormones,contributes toslow weight gain.At high levels alsoinhibits release ofgrowth hormone.
  67. 67. It takes 30 to 60 minutesto lower somatostatinand other stress hormonesSLEEPVITAL !!!
  68. 68. DISSOCIATED INFANTWILL NOT SHOWFEEDING CUES
  69. 69. SEESMum’s eyesHand TOUCHMum’s skinSkin-to-skinCONTACTSENSATIONS THAT WIRE BRAINBack FEELSMum’s armholdingTASTESMum’s milkEar HEARSMum’s voiceSMELLSMum’s milkWARMED onMum’s frontMOVESwith MumSlide from JILL BERGMAN
  70. 70. TRIGLYCERIDELeft : glycerol,Right: palmitic acid,oleic acid, alpha-linolenic acidIn phosphoglycerides,glycerol molecule same:two fatty acids esterifiedPhospholipids area major component of allbiological membranes,Sphingomyelin particularlyconcentrated in BRAINmajor part of MYELIN.
  71. 71. TRIGLYCERIDEMYELIN.Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year ....At one year: human milk has less protein,but MORE TRIGLYCERIDE !!!FATTY ACIDS ARESPECIES SPECIFIC
  72. 72. Up to 6 months,milk is 7.4% fat,but after 12 months it is 10.7%
  73. 73. CC homozygote for “FADS2”, “missing”NOT Brf DID Brf DID BrfNZ 98.4 103.2 98.9UK 97.3 104.0 100.7
  74. 74. BREASTFEEDINGAND BREAST MILKINCREASE IQ
  75. 75. BOTTLE FEEDING& FORMULADECREASE IQ
  76. 76. Be sure the wet nurse has plenty of milk ...because if she lacks it she may give the babymilk of a goat or sheep or some other animal,because the child ... nourished on animal milkdoes not have perfect wits like one fed onwoman’s milk and always looks stupid andvacant and not right in the head.14th century Tuscan text
  77. 77. BOTTLE FEEDING& FORMULADECREASE IQ
  78. 78. Human Milk Banking Associationof North America•Setting the Standards for Human Milk Banking•Meeting the Milk Banking Needs for North America•A Safe Alternative in the Absence of Infants Own MothersThis website is designed to provide information onmilk banking and how to contact a milk bank todonate milk or to order donor human milk. Thissite is also a resource for health care providers andothers who are looking for information onHMBANAs resources and services.http://www.hmbana.org/
  79. 79. "Where it is not possible for the biologicalmother to breastfeed, the first alternative, ifavailable, should be the use of human breastmilk from other sources. Human milk banksshould be made available in appropriatesituations."World Health Organization/UnitedNations Childrens Fundhttp://www.breastmilkproject.org/
  80. 80. INFANT FEEDING FREQUENCY:available evidence & neuroscienceReferences in this formatOVERVIEW:New section this backgroundNeuroscienceAnatomy & physiologyAvailable evidenceProposal feeding frequencyImplications85
  81. 81. "I have finally cum to the konklusionthat a good reliable set ov bowelsiz worth more to a manthan enny quantity of brains.“Josh Billingshttp://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/anatomy.html
  82. 82. CNSENSANSInternalSomaticenvironmentCNS: cortical / subcortical(also to PNS)ANS: emotional / limbic brain(incl SNS)ANS: myelinated vagus (NA)ANS: unmyelinated vagus (DMC)sub-diaphragmaticENS: submucous plexusmyenteric plexus87
  83. 83. The digestive system is endowed with itsown, local nervous system referred to asthe enteric or intrinsic nervous system.The magnitude and complexity of the entericnervous system is immense - it contains asmany neurons as the spinal cord.ENTERIC NERVOUS SYSTEM !!88
  84. 84. CEPHALIC PHASEGASTRIC PHASEINTESTINAL PHASEFEEDBACK LOOPSCNSENSANSInternalSomaticenvironment89
  85. 85. Functional at end of first trimester,begins very early, experience dependent“effective from 29w GA”  significantSMELL“Olfaction in the fetal andpremature infant:functional status andclinical implications”Benoist SCHAALENSANS BreastSensory environment :Intrusive(pain) SupportiveInternalSomaticenvironmentExpectedexternalenvironmentSchaal 2004 90
  86. 86. modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviourSMELLSchaal 2004 91
  87. 87. Perinatal brains showorientations towards“neonatal olfactoryexpectations”When provided:calming, autonomic orientation, activeapproach, metabolic conservation.When not fulfilled:withdrawal, autonomic defense & distressbehaviours, metabolic expenditureSchaal 2004 92
  88. 88. DOUCETThe secretion of Areolar (Montgomery‟s) Glands fromLactating Women Elicits Selective, UnconditionalResponses in Neonates“… breast chemosignalsactivate oral activity on thenipple that releases a cascadeof behavioral, neural, neuroendocrineand endocrine processesin the newborn and the mother.”Doucet 2009 93
  89. 89. The secretion of Areolar(Montgomery‟s) Glands“In early ontogeny thesleeping brain may thusremain sentient of anorganism‟s odorenvironment.”Doucet 2009 94
  90. 90. INFANT FEEDING FREQUENCY:available evidence & neuroscienceOVERVIEW:NeuroscienceAnatomy & physiologyAvailable evidenceProposal feeding frequencyImplications95
  91. 91. 96
  92. 92. Fetal stomach appears 4 weeks GA.By 11 weeks, wall capable of muscularcontraction.“Patterns of antropyloric motilityin fed healthy preterm infants”... the neuroregulatory mechanismsresponsible for the coordination of antro-pyloric motility and gastric emptying arewell developed by 30 weeks of PMA.Hassan 2002 97
  93. 93. Hydrochloric acidimportant for activation of pepsinogen,inactivation of microorganisms such as bacteria.Pepsinogenactivated by acid into active pepsin,responsible for the stomachs ability to initiatedigestion of proteins.Chymosinis an enzyme whose role is to curdle orcoagulate milk in the stomach, a process ofconsiderable importance in the very young animal.98
  94. 94. Chymosinmakes the milk into “cheese”halfway between liquid and solidstomach empties in 60 minutesmilk99
  95. 95. Gut hormones.20 different hormoneswork in the gut –regulated by the vagal nerve.Each has a specific function.Uvnas-Moberg 1989 100
  96. 96. CEPHALIC PHASEGASTRIC PHASEINTESTINAL PHASEFEEDBACK LOOPS101
  97. 97. Gut hormones."Bad guy" - SOMATOSTATIN:(produced by fetus, rise 10-fold under stress)inhibits gastrointestinal secretion,inhibits motility ,reduces blood flow to gutand absorption,causes gastric retention,vomiting, constipation.Uvnas-Moberg 1989 102
  98. 98. SOMATOSTATIN:inhibits the good hormones,contributes toslow weight gain.At high levels alsoinhibits release ofgrowth hormone.Uvnas-Moberg 1989 103
  99. 99. It takes 30 to 60 minutesof SSC to lower somatostatinand other stress hormonesSSC &SLEEPVITAL !!!104
  100. 100. The “niche” (occupation) of a neonate (Alberts)BOND FEEDSLEEP  SLEEPPLAY FEEDAlberts 1994 105
  101. 101. Enteric Nervous SystemThe “niche” (occupation) of a neonate (Alberts)BOND FEEDSLEEP  SLEEPPLAY FEED106
  102. 102. EVIDENCEFORFEEDINGFREQUENCY????Edmond 2006 107
  103. 103. Breastfeeding and mother’s milk:Strong and consistent evidence 108
  104. 104. Cup feeding versus bottle feeding:Cup feeding higher breastfeedinggreater stability 109
  105. 105. Only case series ...Insufficient evidenceNo mention ofstomach capacity110
  106. 106. EVIDENCEFORSTOMACHCAPACITY????Edmond 2006 111
  107. 107. 00.511.522.533.540 10 20 30 40 50 60 70 80volume ingestedfeedingfrequencyAssumption: 3kg baby,requiring 160 ml/kg/daydaily requirement = 480mlStandardCARE:3 hourlyschedule112
  108. 108. KEY QUESTION:WHAT IS THESTOMACHVOLUMEOF THENEONATE ??? 113
  109. 109. Goldstein 1987LengthTransverseAP diameterUsing+2SD 114
  110. 110. Formula for calculation of stomach capacity (Charles Bradshaw, UCT)Assumptions: the stomach can be approximated by dividing intothree sections, namely a ellipsoidal hemisphere, an ellipsoidal cylinder,and a skewed ellipsoidal cone.Variables: a = anteroposterior radius, t = transverse radius, l = length stomachRelations: the height of the cone and the hemisphere are both the same as „a‟.Ellipsoid = 4/3 * Pi* r1*r2*r3 = 4/3 *Pi * a * a * t;therefore volume of hemisphere = 2/3 Pi * a *a * tCylinder = Area of base * height = (Pi * a * t ) * ( l - 2a )Skewed cone = 1/3 * base *height = 1/3 * Pi * a * t * aTotal volume = 2/3 * Pi *a*a*t + Pi * a * t * (l- 2a) + 1/3 * Pi * a * t * a=Pi a*t*l -Pi * a *a*t= Pi * a * t*(l-a)Goldstein and Sase data:Stomach capacity at term 10 - 15 mlBRADSHAW formula115
  111. 111. Assumption: 2,5 kg baby 33w GA,requiring 150 ml/kg/day = 375 ml45 MIN CYCLES ( 32 cycles/day)12 ML PER CYCLE = 384 ml116
  112. 112. Newborn stomach volume.Gastric volumes at birthCorrelated with gastric pH,gastrin and somatostatin “fetus drinks 10 ml portionsof amniotic fluid …”Widstrom 1988 117
  113. 113. Only recent study located:“Autopsy” capacity was determinedin Indian post-mortem studies100 autopsies (63 SB, 37 ENND)Tied at cardia and pylorus, filled withwater, emptied & measured, repeated,“… obliteration of the gastric curvatures”“due care to minimize stretch artifacts”Naveed 1992“An Autopsy Study of Relationship betweenPerinatal Stomach Capacity and Birth Weight.”118
  114. 114. Infants above 2500g only:Ave RangeStillborn (n 11) 19.6 ml (10-35)Early death (n 9) 17.8 ml (10-25)All cases (n 20) 18.8 mlNaveed 1992“An Autopsy Study of Relationship betweenPerinatal Stomach Capacity and Birth Weight.”119
  115. 115. 120KERNESSUK 1997 (Russian)Postmortem: in situ measures(applied Bradshaw formula)AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
  116. 116. Known references with data:Scammon and Doyle 1920Zuccarelli‟s method: stomach filled atautopsy to “a pressure of between15 and 20 centimeters of water”Scammon 1920“Observations of the capacity of the stomach inthe first ten days of post natal life.”121
  117. 117. Anatomic capacity was determinedin post-mortem studiesMain data set  Alliot 1905 (n 25)Scammon own cases ? (n 13)30 – 35 ml at birth –almost regardless of birth weightScammon 1920“Observations of the capacity of the stomach inthe first ten days of post natal life.”122
  118. 118. Known references with data:Scammon and Doyle 1920quoted in Silverman 196114571 feeding records from 323 newborns“physiologic capacity”  all breastfedtest weighing before and after feedingScammon 1920“Observations of the capacity of the stomach inthe first ten days of post natal life.”123
  119. 119. “… modern infant feeding.” “infants were breastfed 5 times per day”INFERENCE?? If fed 5 x per dayand daily requirement 160 ml x 3kg = 480Required volume: 480 / 5 = 96 mlsDid not measure stomach capacity:Pre-determined a feeding frequency!Scammon 1920 124
  120. 120. “… modern infant feeding.”  5 per dayDid not measure stomach capacity:Pre-determined a feeding frequency!“ … the figures … presented here aredistinctly higher than those of earlierinvestigators … not surprising considering… (they) made their observations uponinfants which were fed eight or moretimes per day.”Scammon 1920 125
  121. 121. Imagine a study !!Let us measure the stomach capacitywith a balloon ... at end of NGTTest the pressure on adultsmust not be uncomfortableOnce the pressure starts to rise: there is risk for reflux to be avoided – expected physiologyTHIS SHOULD BE THESTOMACH CAPACITY126
  122. 122. Imagined study was done!!Zangen S et al 2001Rapid Maturation of Gastric Relaxationin Newborn InfantsZangen 2001No reference given ....12775 ml per feeding
  123. 123. Zangen S et alRapid maturation of gastric relaxation in newbornsPressures (mmHg)Balloon inflates to15 ml no increasefunctionalcapacity128
  124. 124. TERMINOLOGY PROPOSALS“Functional capacity”equivalent to “expectation volume”,for which optimal pepsin / acid is made,does not cause distentionallows adequate time for curdleallows protein breakdownallows controlled pyloric passage129
  125. 125. Zangen S et alRapid maturation of gastric relaxation in newbornsPressures (mmHg)Balloon inflates to15 ml no increase20 ml pressure OKphysiologicalcapacity …. 130
  126. 126. TERMINOLOGY PROPOSALSPhysiological capacityMaximal amount stomach can handlewithout undue stress.“Receptive capacity” of STOMACHmaximal amount stretched organ holds“Ingestive capacity” of BABYamount baby or infant swallowed,(note, excess not in stomach) 131
  127. 127. Physiological capacityMaximal amount stomach can handlewithout undue stress.“Receptive capacity” of STOMACHmaximal amount stretched organ holds“Ingestive capacity” of BABYamount baby or infant swallowed,(note, excess not in stomach)Scammon and Doyle did draw attention to this also ....132
  128. 128. EVIDENCE: (NBn 111009)Author Capacity Note:Sase 10-15 ml Live, term fetusGoldstein 10-15 ml Live, term fetusWidstrom 10 mls Live, newbornZangen 20 mls Live, (pressure)Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water(Alliot) pressure)133
  129. 129. PROPOSAL:The CAPACITY of aweek old baby‟sstomach isapprox 20 ml.134
  130. 130. INFANT FEEDING FREQUENCY:available evidence & neuroscienceOVERVIEW:NeuroscienceAnatomy & physiologyAvailable evidenceProposal feeding frequencyImplications135
  131. 131. 00.511.522.533.540 10 20 30 40 50 60 70 80volume ingestedfeedingfrequencyAssumption: 3kg baby,requiring 160 ml/kg/daydaily requirement = 480mlStandardCARE:3 hourlyscheduleMOTHERNATURE:1 hourlyschedule136
  132. 132. PHYSIOLOGICAL CAPACITYRECEPTIVE CAPACITY of stomachINGESTIVE CAPACITY of BABYFUNCTIONAL CAPACITY137
  133. 133. PROPOSAL:The FEEDINGFREQUENCY of theNEONATE isapprox 60 min.138
  134. 134. CEPHALIC PHASEGASTRIC PHASEINTESTINAL PHASEBRAIN CYCLINGSTOMACH FILLING & EMPTYINGREMNR1NR2NR3NR4139
  135. 135. Normal physiology of theEnteric Nervous System“Small and frequent feeds,according to the sleep cycle”The “niche” (occupation) of a neonate (Alberts)BOND FEEDSLEEP  SLEEPPLAY FEED140
  136. 136. INFANT FEEDING FREQUENCY:available evidence & neuroscienceOVERVIEW:NeuroscienceAnatomy & physiologyAvailable evidenceProposal feeding frequencyImplications141
  137. 137. Zangen S et alRapid maturation of gastric relaxation in newbornsA balloon in stomachcan fill to 76 mlsWhat does thestomach –without a balloon –do to 76 mls?REFLUX !!!PRESUME: each feedapproximately 75 mlsZangen 2001 142
  138. 138. WHERE IS THE MILK?This volumeis not inthe stomachStomachStomachStomach143
  139. 139. WHERE IS THE MILK?Mother’s shoulderOesophagusDuodenumDuodenumStomachStomachStomachHow To Do Just AboutEverythingHow to Burp a BabyBurping a babycan reducespitting up andrelieve bloatingcaused byswallowed air.Here are sometried-and-truemethods.144
  140. 140. WHERE IS THE MILK?How To Do Just AboutEverythingHow to Burp a BabyBurping a babycan reducespitting up andrelieve bloatingcaused byswallowed air.Here are sometried-and-truemethods.What happens when my babyspits up?Babies spit up when theyve eatentoo much or when theyre burped. Itcan also happen when your baby isdrooling.Spitting up is not vomiting.Babies usually dont notice whenthey spit up, while vomiting isforceful and painful. Spitting up is acommon occurrence for mostbabies.http://familydoctor.org/online/famdocen/home/children/parents/infants/218.htmlCopyright © 1996-2007 American Academy of Family Physicians145
  141. 141. WHERE IS THE MILK?What happens when my babyspits up?Babies spit up when theyve eatentoo much or when theyre burped. Itcan also happen when your baby isdrooling.Spitting up is not vomiting.Spitting up is REFLUX.Nils Bergman, 2011146
  142. 142. Blood sugar may fall …after 90 minutes ...“There is areason behindeverythingin nature” AristotleWould nature allow this?147
  143. 143. HYPOGLYCAEMIAA babies stomachempties in60 minutes.Blood sugarmay fall …after 90 minutes ...Option?HOURLY FEEDING.148
  144. 144. Large volume feedsstretched stomach=doubled absorptivecapacity as adultStettler 2005Stettler et alWeight Gain in the First Week of Life and Overweight in Adulthood:A Cohort Study of European American Subjects Fed Infant Formula149
  145. 145. This finding is important,not so much to predictwhich infants are at riskfor becoming overweightadults, but more to under-stand the importance ofthe human physiologyof programming duringshort early-life periodson the development ofchronic disease over thelife course.Stettler et alWeight Gain in the First Week of Life and Overweight in Adulthood:A Cohort Study of European American Subjects Fed Infant Formula150
  146. 146. Gastric overfilling syndrome?Excessive volumesreflux, aspiration, colicExcessive time intervalhypoglycaemiaAdaptationsdiabetic diathesis, obesity151
  147. 147. Developmental Care of theEnteric Nervous System“Small and frequent feeds, accordingto the sleep cycle”The “niche” (occupation) of a neonate (Alberts)BOND FEEDSLEEP  SLEEPPLAY FEED152
  148. 148. WHAT IS THESTOMACHVOLUMEOF THEPREMATURE ??153
  149. 149. Assume low resilienceAssume proportionality 154
  150. 150. The CAPACITY of alow birthweight premfrom 20ml / 3000g= 0.007 x BWt (g)1kg x 0.007 = 7mls2kg x 0.007 = 14mls155
  151. 151. Baby weight; freq; req’d size  actual2kg baby: 4hrly~ 320 ml/6 = 53ml  14ml1,5 baby: 3hrly~ 240 ml/8 = 30ml  10ml1,0 baby: 2hrly~ 160 ml/12 = 13ml  7mlStandardised from20ml capacityfor 3kg baby( x 0.007)156
  152. 152. 010203040506070809013w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52wLINEARTERMPREM157
  153. 153. 010203040506070809013w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52wLINEARTERMPREM158
  154. 154. Proposed Management Babies should be fedEVERY TIME THEY WAKE !! 159
  155. 155. Proposed Management All babies should be fedat least once an hour !! 160
  156. 156. Proposed Management All babies should be fedat least once an hour !!161
  157. 157. The first Milk Ejection Reflex(MER)elicited in < 2 minutesworks quicklyswallowed 1 minuteFeeding time (max)3 minutesRepeat every 1 hourPrime 2007
  158. 158. The “normal” or usual andcommon breastfeedtakes 15 minutesdiscomfort afterburping time 5 minutesFeeding time 20 minRepeat every 3 hoursPrime 2007
  159. 159. 3 minute 20ml feeds x 24/d = 72 minutes20 minute 60ml feeds x 8/d = 160 minutesSMALL AND FREQUENT FEEDSARE EFFICIENT !!!!FEWER NURSES NEEDED !!!
  160. 160. The calculated dailyrequirement for a 3kgbaby can be givenwithout increase inpressure .... MINIMAL RISKPARENTS CAN DOSAFELY !20 mls x 24 feeds= 480mls / dayZangen 2001 165
  161. 161. All babies should be fedat least once an hour !!166
  162. 162. First two days: COLOSTRUM15 mls / day (Paula Meier)“one teaspoon,three times a day”From third day: MILKsmall frequent feeds(on demand)between sleepsAvailable from Geddes Productions
  163. 163. Infant feeding frequency:Proposal based on availableevidence and neuroscience“Small andfrequent feeds,adjusted tothe sleep cycle”168
  164. 164. In the past, whetherto breastfeed or notwas a lifestyle choice.Our new knowledge of the brainmakes breastfeedinga public health issue.(Gail Storr, Fredericton, NB)
  165. 165. SUMMARY !!SKIN-TO-SKIN(Regulation)SLEEP(Brain)FEEDING(Stomach)LOVE !( “mind” )

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